Request for Access to Health Information

By submitting this request, I understand that:

• Connxus operates as a Health Information Exchange and maintains health information received from participating providers and partners.
• Connxus will provide access to health information maintained within its systems.
• Connxus may not maintain a complete medical record. Additional records may be available directly from healthcare providers. A list of participating providers is available on the Connxus website.
• My request will be processed in accordance with applicable law, including the Health Insurance Portability and Accountability Act (HIPAA) and Texas Health & Safety Code Chapter 181.
• Connxus will make reasonable efforts to provide the requested information within 15 business days of receiving a complete request.
• Connxus may verify my identity prior to releasing health information and may deny or limit requests as permitted by law.

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Name *

First

Last

Date of Birth *

Street Address *

City, State, Zip Code *

Phone Number *

Email *

Name of Requester

If not the patient

Relationship to Patient *--- Select Choice ---SelfParentLegal GuardianPersonal RepresentativeOther

Type of Information RequestClinical (e.g., Visits, Diagnosis, Medications, etc.)Social Needs/SDOH Assessment and ReferralsOther

Information Request Description

If you selected Other, please specify here.

Method of Date

Date Range of Request

From Start Date - End Date

Delivery Method Secure EmailMail (Paper Copy)

Submit